Terrible Medication Error

Nurses Medications

Published

I made the worst medication error today and feel so horrible about it. I literally wanted to quit the job from sadness and embarrassment. I'm a new nurse and have only been working at the hospital for about 5 months. I've been a nurse for about 10 months.

I had a patient on a Lasix drip that was 100ml total volume. 100 mg in 90ml which calculated out to be given 5ml/hr. This may sound confusing but long story short I infused the medication at 100ml/hr instead of 5ml/hr because I was looking at the 100mg in 90ml and I was also looking at the 100 ml total volume instead of paying attention to the 5ml/hr like I should have. I and the charge nurse caught the error but 75ml had already gone in a little over 3 hrs when this medication should have lasted for almost 20 hrs if it was done correctly.

We contacted the doctor he said to just monitor him, I filled out an incident report, and we restarted the infusion at the correct dose. I believe I got confused because of all the different numbers on the IV bag and I was also very busy that night. The result of this was critical potassium of 2.1!! we luckily had a potassium protocol to start potassium IV 50ml/hr for 6 bags total and recheck the level. I felt humiliated!! and so embarrassed.

I knew everyone had known my mistake because a random nurse came to me and asked me if I was ok. I knew he was asking this because the charge nurse must've told him what happened. I feel so dumb and incompetent as a nurse. I don't know how I will face this at work tomorrow. Not to mention we do this thing called line up at the start of shift where we discuss things that are going on in the hospital and on the unit and we talk about bad mistakes that nurses make throughout the hospital. I'm sure this is bad enough to be talked about during line up.

Although they don't say the name of the person who made the mistake I know everyone will know it was me, and of course, I will know it's me they're talking about! What makes it even worse is they read the same scenarios in a line up every day until a new situation happens that they can add to the lineup discussion. I will be so embarrassed every time they talk about this in the lineup. How do I come back from this? I feel like the worse person and nurse ever. I can't even think straight. I still don't know what penalty I will face yet but I'm praying I don't get fired.

Lastly, the worst part of this situation is. When it was time to hang the potassium my charge nurse caught me off guard because I was already anxious and nervous and asked me what I would run the potassium at if it was 50ml per hr, just to be sure I would hang the IV correctly. I accidentally said 25ml instead of 50ml because I get so nervous when I'm caught on the spot and asked questions. I'm sure she thinks I'm a complete idiot. I feel like my life is ruined!! IDK what to do. What if nursing just isn't the profession for me after I've worked so hard for it, I'm so distraught!

HUGS to you. Listen, everyone makes mistakes. Just last weekend at work, an experienced nurse gave a medication in the am, that was written for pm. It happens!!! The patient is fine, you owned it right away, it doesn't make you less of a nurse. It makes you human. And I would bet my life that you will double and triple all infusions from here on it. Try to relax now!

2 Votes
Specializes in Critical Care.

Depending on the specific degree of med error, our facility makes the RN go to a quality assurance briefing.

Did you say that the labels are hard to read?

Maybe this is something you can bring up in a quality meeting. It is not making excuses if you earnestly believe the labeling is confusing. Perhaps it is.

Perhaps you need to focus more intently. Who knows. That's why its a review. ?

Best of luck,

1 Votes
Specializes in Gerontology, Med surg, Home Health.

You all stand around at the start of the shift and discuss everyone who's made a mistake? That sounds just plain horrible and doesn't serve any purpose. Learn from your mistake, be thankful no one was harmed, and move on.

2 Votes
Specializes in Pain, critical care, administration, med.

Stop beating yourself up. We have all made mistakes and the best lesson out if it is we will never make that mistake again. Don't worry what others think and this is a benefit to your peers to hear of errors. We often get lazy and at times cocky we need these lessons learned as a way for us to be paying attention.

1 Votes
Specializes in LTC, assisted living, med-surg, psych.

The only nurses who say they've never committed a med error are either fresh out of school or lying.

Also, there are two kinds of nurses: the kind who've made a med error, and the kind who will.

Learn from this, and move forward. You did all the right things in following up on your mistake, and the patient is OK. It could've been a lot worse if you hadn't caught it as quickly as you did. You did fine. And I think it's a safe bet that you'll never make another one like it. :yes:

4 Votes
Specializes in ICU, telemetry, LTAC.

I've seen patients get 80 mg IV Lasix as an IV push, given over oh, ten minutes or so... Of course for those patients, there was backup potassium ordered. There should have been as well, for your patient on a Lasix drip. It takes a day or two to get over the adrenaline rush (bad rush, it's scary as heck) of a med error but just analyze, remember how you made the mistake and avoid doing that again. You are doing fine. You caught it, figured it out, reported it, fixed it, didn't kill the patient, and the next step is to go back to work and hold your head up, and just work. It'll be all right in the end.

I misread a computer printout from a dinosaur system when I was brand new, checked it twice with my preceptor, and gave mag citrate to a dude who was only gonna have an upper GI and only needed to be NPO after midnight. What a fun night. Lesson learned: don't be in too big a hurry to make someone poop all night, make sure they REALLY need it first. I was embarrassed, the patient was 10 lbs lighter in the morning, but it all worked out.

Edit to add: they fixed the computer instructions very shortly after that.

1 Votes

We all do it. Some nurses say they have never made a med error - I guarantee if they have been a nurse very long they have made some type of med error. Either they are lying (which I hope not), or they didn't catch the med error. Example - an antibiotic was due at supper for a patient and they got two capsules. I only gave them one and had no clue I had made an error until the next day when I worked and saw that the patient was to receive two capsules - that is when I realized I had only given them one capsule the evening before. Had I not worked that second day on that same unit, I would have never known I had made the med error.

If it makes you feel more comfortable, double check the rate on your IV bags with another nurse until you gain your confidence back. Yes, they will all talk about you - mostly because they are breathing a sigh of relief it wasn't them that made that particular error, but you can bet at some point most of them will make one.

I do think it is a good idea to discuss mistakes made as it can help other nurses from making the same mistake, but I think they can present it at a different time and in a different manner, use it more as a learning tool.

3 Votes
Specializes in Cardiopulmonary Stepdown/Cath Lab, ICU.
Indy said:
I've seen patients get 80 mg IV Lasix as an IV push, given over oh, ten minutes or so... Of course for those patients, there was backup potassium ordered. There should have been as well, for your patient on a Lasix drip. It takes a day or two to get over the adrenaline rush (bad rush, it's scary as heck) of a med error but just analyze, remember how you made the mistake and avoid doing that again. You are doing fine. You caught it, figured it out, reported it, fixed it, didn't kill the patient, and the next step is to go back to work and hold your head up, and just work. It'll be all right in the end.

This, that's a bolus for some of our CHFers. Didn't your nursing instructors ever tell you-you weren't going to be perfect as a new nurse? I know mine made it very clear to us that mistakes will most likely happen at some point.

They may pull you aside to talk about it, to see if there was a "procedural" error (i.e. the difficult to read IV bag). And you may get a ding on a review, but again you are a new nurse and no harm came to the patient. They aren't going to fire you over one error, it's only an issue if they start to pile up, which after this, I'm sure they won't

1 Votes

Anybody who says they haven't made a mistake is normally lying, told to me by matron when I have the wrong patient beta blocker, the embarrassment will go away, in the lineup you should declare it's you seeing as though they already know, explain what happens how they mistake came to be and explain also how you feel, it's a learning experience for you all. But most don't beat yourself up about it, you feel bad. It would be so much more worrying if you didn't care, and most important thing patient fine.

1 Votes
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
rekea526 said:
I made the worst medication error today and feel so horrible about it. I literally wanted to quit the job from sadness and embarrassment. I'm a new nurse and have only been working at the hospital for about 5 months. I've been a nurse for about 10 months. I had a patient on a Lasix drip that was 100ml total volume. 100 mg in 90ml which calculated out to be given 5ml/hr. This may sound confusing but long story short I infused the medication at 100ml/hr instead of 5ml/hr because I was looking at the l00mg in 90ml and I was also looking at the 100 ml total volume instead of paying attention to the 5ml/hr like I should have. I and the charge nurse caught the error but 75ml had already gone in a little over 3 hrs when this medication should have lasted for almost 20 hrs if it was done correctly. We contacted the doctor he said to just monitor him, I filled out an incident report, and we restarted the infusion at the correct dose. I believe I got confused because of all the different numbers on the IV bag and I was also very busy that night. The result of this was critical potassium of 2.1!! we luckily had a potassium protocol to start potassium IV 50ml/hr for 6 bags total and recheck the level. I felt humiliated!! and so embarrassed. I knew everyone had known my mistake because a random nurse came to me and asked me if I was ok. I knew he was asking this because the charge nurse must've told him what happened. I feel so dumb and incompetent as a nurse. I don't know how I will face this at work tomorrow. Not to mention we do this thing called line up at the start of shift where we discuss things that are going on in the hospital and on the unit and we talk about bad mistakes that nurses make throughout the hospital. I'm sure this is bad enough to be talked about during line up. Although they don't say the name of the person who made the mistake I know everyone will know it was me, and of course, I will know it's me they're talking about! What makes it even worse is they read the same scenarios in a line up every day until a new situation happens that they can add to the lineup discussion. I will be so embarrassed every time they talk about this in the lineup. How do I come back from this? I feel like the worse person and nurse ever. I can't even think straight. I still don't know what penalty I will face yet but I'm praying I don't get fired. Lastly, the worst part of this situation is. When it was time to hang the potassium my charge nurse caught me off guard because I was already anxious and nervous and asked me what I would run the potassium at if it was 50ml per hr, just to be sure I would hang the IV correctly. I accidentally said 25ml instead of 50ml because I get so nervous when I'm caught on the spot and asked questions. I'm sure she thinks I'm a complete idiot. I feel like my life is ruined!! IDK what to do. What if nursing just isn't the profession for me after I've worked so hard for it, I'm so distraught!

Oh my goodness! Take a deep breath! You made a medication error -- everyone makes them. This wasn't the worst medication error that you could have made, and it sounds as if the only injury was to your pride and not to the patient. That's a good thing! You caught the error and immediately reported it then set about doing what you could to mitigate the damage to the patient. That's what you're supposed to do. Presumably, you've also learned from your mistake.

Everyone makes mistakes. Absolutely everyone. If you ever find someone who says they've never made a mistake, they're either lying o you or complete idiots who haven't realized they've made a mistake. This is not the end of the world. You'll get over it. In the meantime, focus on the positive. You made the mistake, but you recognized it admitted to it and then started to mitigate the damage. You did what you were supposed to do. Good on you!.

1 Votes
Specializes in Trauma/Tele/Surgery/SICU.

Recovering from a medication error will take some time. It is a shocking experience that causes a lot of self-doubts. The feelings you are experiencing right now are perfectly normal. The key is to not let this anxiety and doubt paralyze you. We have all had experiences in our life where we make one error and then it seems to snowball...with the anxiety contributing to even more errors. You reference this in your post when you speak of the potassium. For your situation, this is bound to be magnified by the thought of everyone discussing you, analyzing you, etc. etc.

First, know that what the previous posters have said is absolutely true! Every nurse new or old makes an error. It is part of being human. Some of us may have been lucky enough thus far in our careers, to not have made a very serious med error, not because we are some super awesome nurse, but because we have been lucky. But for the grace of God go I. This is so very true!

This one error does not make you a horrible nurse or mean you are not cut out for this job! I would be very surprised if you were fired for this error.

You may find that you need a day off to process this. Do not feel bad if you do. Going straight back the next day after making an error may be too much for you. If you find this is true, call your manager right away and discuss this with him/her. When you do return know that people will absolutely talk about this. They always do. Most of us discuss med errors made by others not out of maliciousness but because we want to prevent it from happening to us. There is a small percentage of those who take glee in others mistakes. Those people are not worth your consideration. They use other peoples misery to make themselves feel superior. Recognize this for what it is a sign of insecurity that is not reflective of you at all. They would do this to anyone who made an error!

What you can do for your own professional growth is really analyze what you feel contributed to this error. You mentioned you were rushed and that the IV bag label confused you. What other factors do you feel contributed? Ratio? The acuity of pt.s? Unfamiliarity with the medication? Are you under stress at home? etc. You may find through your self-reflection a systems error that could help make your facility safer in the future. One that I see right away from your post is the medication label. When we generate a label for a drip, even a titratable one, we have to put in the starting dose it is ordered at. The label will then tell us the rate the drip should be infused at for that dosage. A second issue that I see is the IV pump. Is it a smart pump? The pumps that we use would not have allowed us to program an infusion of Lasix for this rate. If you hang a lot of potentially dangerous meds this may be something your unit might benefit from. Perhaps you could bring these points up during the "line-up."

Do not feel embarrassed when this is discussed in your unit. It would have been very easy for you to have covered this error up had you really wanted to. It takes great bravery and shows a true concern for your patient's well-being, to fess up and deal with the fallout. Many people hide their mistakes! I would be really tempted to say "Hey guys I am that Lasix nurse and this is what this error has taught me" during the line-up. Hold your head up high when you return to work. Aside from never making an error at all you did the best possible thing: minimizing the potential damage by admitting to what happened and alerting the physician.

2 Votes
Specializes in kids.

Ahh. A med error...is a HORRIFYING experience!!!!

You cannot undo it and you have to sit back and make a plan to NEVER do that again.

But the important thing here is this: You quickly realized and rectified your error.

You need to remember that you are not the first, nor the last to make an error. Take the opportunity to work with the hospital on fixing the label issue. Maybe be a perfect way to help you see that good can come out of a "Human" mistake.

Hugs!

1 Votes
+ Add a Comment